Chapter 15: Health Assessment and Physical Examination

Chapter 15: Health Assessment
and Physical Examination
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Some material previously published. Slide 1
Purposes of Physical
Examination
 Gather baseline data
 Supplement, confirm, or refute data
 Confirm and identify nursing diagnoses
 Make clinical judgments
 Evaluate the outcomes of care
Cultural Sensitivity
 Cultural differences influence a patient’s
behavior
 Recognition of cultural diversity helps to
respect the patient
 Consider a patient’s
 Health beliefs
 Use of alternative therapies
 Nutritional habits
 Family relationships
 Use of personal space
Inspection
 The use of vision and hearing to distinguish
normal from abnormal findings
 Use adequate lighting
 Position and expose body parts
 Inspect for size, shape, color, symmetry, position,
and abnormalities
 Side to side comparison
 Pay attention to detail
Palpation
 Involves using the hands
 Examine accessible body parts
 Palpate skin
 Temperature, moisture, texture, turgor,
tenderness, and thickness
 Palpate abdomen
 Tenderness, distention, or masses
Percussion
 Tapping the body with fingertips to produce a
vibration
 Character of sound
 Determines location, size, and density of
structures
 Depends on the density of tissues
 Abnormal sounds can be mass, air, or fluid
Auscultation
 Listening to sounds produced by the body
 Assess sounds heard in the heart, lungs, and
gastrointestinal systems
 Requires the use of a stethoscope
 Characteristics include
 Frequency
 Loudness
 Quality
 Duration
Olfaction
 To identify nature and source of body odors
 Helps to detect abnormalities
 Used in conjunction with other measurements
Preparation for
Assessment
Environment Equipment
Physical Preparation Positioning
Psychological Preparation Assessment of Age-Group
General Survey
 Begins when you first meet a patient
 Begins with review of primary health pattern
 The survey provides information regarding
 Characteristic of illness
 Hygiene
 Skin condition
 Body image
 Emotional state
 Developmental status
General Appearance
and Behavior
Gender and Race Age
Signs of Distress Body Type
Posture Gait
Body Movements Hygiene and Grooming
Dress Body Odor
Affect and Mood Speech
Patient Abuse Subculture Abuse
Skin
 Assessment
 Nursing history
 Color
 Moisture
 Temperature
 Texture
 Turgor
 Vascularity
 Edema
 Lesions
Hair and Scalp
 Use inspection
 Assess
 Distribution
 Thickness
 Texture
 Lubrication
Nails
 Inspection and palpation
 Condition of nails reflects
 General health
 Nutritional status
 Occupations
 Level of self-care
Head and Neck
 Assess
 Headache, dizziness, seizures, poor vision, loss
of consciousness
 Head size, shape contour of head and skull
 Facial symmetry
Eyes
 Visual acuity
 Ability to see small details
 Visual fields
 Test of peripheral vision
 External and internal eye structures
Nose and Sinuses
 Assess for exposure to
 Dust
 Pollutants
 Allergies
 Nasal obstruction
 Trauma
 Discharge, postnasal drip
 Headaches
Mouth and Pharynx
 Assesses overall health
 Determine oral hygiene needs
 Develop therapies for dehydration
 Assess oral trauma
 Assess for airway trauma
Neck
 Neck muscles
 Lymph nodes
 Carotid arteries
 Jugular veins
 Thyroid gland
 Trachea
Thorax and Lungs
 Review of ventilatory and respiratory
functions of lungs
 Landmarks help to locate structures
 Inspection, palpation, and auscultation
 Orthopnea
 Dyspnea
 Adventitious breath sounds
 Normal breath sounds
Heart
 Compare assessment of heart function with
findings from vascular assessment
 Heart function is correlated with physiological
events
 Use inspection, palpation, and auscultation
 Pulsations
 Palpate apical pulse
 Auscultate heart sounds
Vascular System
 Measure blood pressure
 Assess integrity of peripheral vascular system
 Use inspection, palpation, and auscultation
Breasts
 Examine both female and male breasts
 Take a health history
 Use inspection and palpation
Abdomen
 Use landmarks to map out the abdominal
regions
 Assess both anterior and posterior
 Examine the liver, stomach kidneys, bladder,
and GI tract
 Conduct a nursing history
 Use inspection, auscultation, and palpation
Female Genitalia
 Examination of the genitalia includes external
and internal sex organs
 Must provide privacy
 Need to understand cultural sensitivity
Male Genitalia
 Assess the integrity of external genitalia,
inguinal ring, and canal
Rectum and Anus
 Perform after genital examination
 Explain all steps to patient
 Provide privacy
Musculoskeletal System
 Visualize the anatomy of bone, muscle, and
joint placement
 Assess
 Range of joint motion
 Muscle strength and tone
Neurological System
 Assess
 Language
 Intellectual function
 Cranial nerve function
 Sensory nerve function
 Motor function
Practice Questions
 1. When meeting a patient for the first time, it is
important to establish a baseline assessment that will
enable a nurse to refer back to which of the
following?
 A. Physiological outcomes of care
 B. The normal range of physical findings
 C. A pattern of findings identified when the patient is
first assessed
 D. Clinical judgments made about a patient’s
changing health status
Practice Questions (continued)
 2. A patient complains of thirst and
headache. The patient appears emaciated.
On initial examination you find that the skin
does not return to normal shape. This finding
is consistent with what condition?
 A. Pallor
 B. Edema
 C. Erythema
 D. Poor skin turgor
 3. A patient is admitted with pneumonia.
When auscultating the patient’s chest, you
hear low-pitched, continuous sounds over the
bronchi. These sounds are identified as
which of the following?
 A. Crackles
 B. Rhonchi
 C. Wheezes
 D. Pleural Rub
 4. When conducting an abdominal
assessment, what is the first skill a nurse puts
to use?
 A. Auscultation
 B. Inspection
 C. Palpation
 D. Percussion

Chapter 15: Health Assessment and Physical Examination

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Chapter 15: Health Assessment and Physical Examination

Uploaded by

Copyright:

Available Formats

Chapter 15: Health Assessment

and Physical Examination

Physical Preparation Positioning

Psychological Preparation Assessment of Age-Group

Signs of Distress Body Type

Body Movements Hygiene and Grooming

Dress Body Odor

Affect and Mood Speech

Patient Abuse Subculture Abuse

 External and internal eye structures

 Assess integrity of peripheral vascular system

 Use inspection, palpation, and auscultation

You might also like